Download Pediatric Resuscitation - Calgary Emergency Medicine

Pediatric Resuscitation
Core Rounds Oct 2007
Marc Francis R5 FRCPC
PEM Fellow year 1
Dr. Roger Galbraith
Objectives
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Case based
Challenges
New revisions to ACLS guidelines
Numbers that will help you in a crunch
Pediatric Airway
IV access
Controversies in resuscitation
Personal reading
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Neonatal Resuscitation
RSI dosing and drugs for pediatrics
Inotropes and Pressors
Detailed management of specific
presentations
Challenges of Pediatric
Resuscitation
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Emotional
Lack of patient verbal skills
Patient fear
Varying normal values for vital signs
IV access
Drug dosing
Technical skills more challenging
Parental presence
Pediatric arrest
• Comprehensive review 1966 – 2004
• 5363 pts in 41 different studies
• 12.1% survived to hospital discharge
• 4% survived neurologically intact
• Better outcomes with
• Trauma arrest
• Submersion injury
• Improved survival with
• Witnessed arrest
• Bystander CPR
• Prospective observational study from a registry of
cardiac arrests
• The rate of survival to hospital discharge
following pulseless cardiac arrest was higher in
children than adults:
27% (236/880) vs 18% (6485/36,902)
adjusted OR = 2.29, 95%CI (1.95-2.68)
• Of these survivors 65% of children and 73% of
adults had good neurological outcome
• First documented pulseless arrest rhythm was
typically asystole or PEA in both children and
adults
• Survival to hospital discharge with asystole and
PEA was:
– 24% in the children (135/563)
– 11% in the adults (2719/24,987)
– OR 2.73 (2.23-3.32)
• Children had better outcomes than adults despite
fewer cardiac arrests due to VF or pulseless VT
Etiologies
Out-of-hospital
• SIDS
• Trauma (most
common > 6 months)
• Submersion
• Sepsis
• Cardiac diagnosis
• Pulmonary disease
In-hospital
• Sepsis
• Respiratory failure
• Drug toxicity
• Metabolic disorders
• Arrhythmias
Generally, of survivors…
Airway intervention saves 90%
IV access saves 9%
Drugs save 1%
Case 1
• You are at your daughter’s soccer game
enjoying a cold one
• There is a large commotion on another pitch
and they call for help
• A 4yo M suddenly collapsed on the field
and is not breathing
• You rush to his side and find him to be
apneic and pulseless….
2005 ACLS
• Simplify resuscitation
training and improve
the effectiveness
Caveats…
• Most pediatric ACLS recommendations are
“class indeterminate”
• Promising but low-level evidence or high-level but
inconsistent evidence
• Extrapolation from adult evidence
• None are “class I”
• At least one RCT with excellent critical assessment
and positive, homogeneous results
2005 ACLS Key Points
• Push hard and fast
• Chest compressions at rate of 100/min
• Limit interruptions in chest compressions
• Universal compression to ventilation ratio
• 30:2 for all lone rescuers
• Each breath should be delivered over 1 second
• Attempted defibrillation than immediate CPR
Compression:Ventilation Ratio
Single Provider
• Universally 30:2 for
all age groups for
single provider CPR
except neonates
2 Provider CPR
• 30:2 for adult 2
providers
• 15:2 for infants and
children two providers
• Continuous
compressions when
advanced airway in
place at 8-10 bpm
Pediatric Chest Compressions
• Rescuers may use 1 or 2 hands to give chest
compressions
– Children >1yo
• press at the nipple line
– Infants <1yo
• Press just below the nipple line
• Use 2 fingers for compression in lone CPR
• 2 thumb encircling technique for 2-provider CPR
Pediatric Chest Compressions
• Compress the chest
1/3 – 1/2 its depth
• Change compression
provider every 2 mins
• Mannekin based study with 40 subjects
• Compressions at 100/min for 2 consecutive periods of
3mins with 30 seconds rest in between
• Number of satisfactory chest compressions performed
decreased progressively during resuscitation (p< 0.001)
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First min = 82/min
Second min = 68/min
Third min = 52/min
Fourth min = 70/min
Fifth min = 44/min
Sixth = 27/min
• Effect was greater in female providers
• Providers did not perceive their own fatigue
• The Coach comes over
and says they have an
adult AED inside the
nearby arena….
• Do you want to use it?
AEDs in Children
• Recommended for children ≥ 1 year old
– In out of hospital arrest use the AED after 5 cycles of
CPR (~2 mins)
– If the available AED does not have child pads can use a
regular AED with adult pads
• Evidence is insufficient to recommend for or
against the use of AEDs in infants under 1 year of
age
– Class Indeterminate
Shock dose
• Biphasic or Monophasic
• Initial Shock dose is the same
– 2J/kg initially
– 4J/kg subsequent
Case 1 con’t
• The AED shows Asystole and no shock is
delivered.
• Paramedics arrives on scene and 3 rounds of
Epi with good CPR are administered with
no effect
• The Medic asks you if he should try high
dose epinephrine???
• Retrospective cohort study comparing high dose epi to
standard epi in OOHCA
• N= 65 pts <18yo
– 40pts (62%) HDE
– 13pts (20%) SDE
• Outcome measures
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ROSC
Return of organized electrical activity
Hospital admission
Hospital discharge
Neuro outcomes
• HDE did not improve the rates of any of the outcomes
High dose Epinephrine
• High dose Epi = 0.1mg/kg IV/IO
– Routine use has never shown a survival benefit
– May be harmful particularly in asphyxia
• Currently is not recommended routinely
– Class III evidence
• Considered only in exceptional
circumstances such as B-blocker overdose
Case 2
• 13 month old Male. Attends daycare.
• Diagnosed with “reactive airways” in the
past
• Mother has ventolin puffer he rarely uses
• Runny nose and cough for 3 days
• Then marked respiratory distress noted last
24hrs and no po intake
• Taken to resuscitation room
Case 2
• Vitals
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T 38.2 °C
HR 179
RR 56
BP 81/56
Sat 88% on RA
Chemstrip 4.6
• Even before you
examine the child….
• What is your
impression of the vital
signs
Pediatric Vitals
Heart rate normals
>200 is abnormal in any age group
>180 is usually abnormal unless in the first year of
life
Normal resting RR
Newborn
Infant (1–6 months)
Infant (6-12 months)
1-4 yrs
4-6 yrs
6-12 yrs
>12 yrs
* >60 abnormal in all age groups
30-60
30-50
24-46
20-30
20-25
16-20
12-16
Estimate of Minimum Systolic BP
Age
0 – 1 month
1mth – 1year
1yr – 10yrs
>10yrs
Minimal Systolic BP
(lowest 5%)
60mmHg
70mmHg
70mmHg + 2 (age)
90mmHg
Less than 60mmHg is always abnormal
Hypotension:
Compensated
vs
decompensated
shock
LATE!
SUDDEN!
Case 2 Continued
• Generally:
– looks unwell, pale and in marked distress
• CVS:
– Tachy, normal HS, cap refill 4 secs, normal pulses
• Resp:
– Tachypneic, suprasternal and scalene retractions, silent
chest
• During next 5 mins patient becomes more drowsy
and lethargic with apneic periods
• What do you want to do now…..
Numbers that can help in a crunch…
• Estimate of weight:
= 8 + 2 (age)
• SBP lowest 5%
= 70 + 2 (age)
• Estimate of tube size:
= age / 4 + 4
• Depth of ETT
insertion:
= ETT Size x 3
• Foley catheter size
= ETT size x2
• NG tube size
= ETT size x 2
• Chest Tube size
= ETT size x 4
What if you can’t remember doses
• Under stressful
situations your brain
turns to mush…
• You stink at math…
BROSELOW TAPE!!!!
• Examined 7500 kids in Ohio
• Compared actual weight to predicted weight
by the Broslow
• Broslow colour predicted by height vs
actual weight
– Overall percentage agreement 66.2%
– Overall Kappa value was 0.61
• Accurately predicted ETT size in 71%
• Tape accurately predicted medication doses
within 10% in 55-60% of patients
• Kids were under dosed (by ≥10%) 2.5 to 4.4
times more often than those over dosed (by
≥10%) p<0.05
• Concluded that the Broselow tape
inaccurately predicts weight in up to 1/3 of
North American kids and could result in
underresuscitation
• A decision is made
that the patient
requires intubation
• What are the issues in
intubating a child?
Differences in Peds Airway
1) Big tongue and more soft tissues
2) Narrowest point at subglottis
3) Anterior/cephalad larynx
4) Short trachea
5) Prominent occiput
6) Big floppy epiglottis
7) Higher metabolic rate
8) Lower FRC
9) More compliant chest wall
10) Smaller airway caliber
Anatomical Differences in Peds
Airway
To cuff or not to cuff….that is the
question
• Cuffed endotracheal tubes may be used in infants
(except newborns) and children in in-hospital
settings provided that cuff inflation pressure is
kept <20 cm H2O
• One randomized controlled trial 3 prospective
cohort studies and 1 cohort study document no
greater risk of complications in children < 8yo
• Khine HH, Corddry DH, Kettrick RG, et al. Comparison of cuffed
and uncuffed endotracheal tubes in young children during general
anesthesia. Anesthesiology. 1997;86:627–631
Case 3
• 3yo M
• Sucking on large jaw breaker candy and
onset of choking
• EMS called and currently on-route to ACH
• Initially coughing and wheezing
• 2 mins out patch saying has become
cyanotic, silent and apneic
• Unresponsive and weak pulse on arrival….
Airway Obstruction
• Signs of severe airway
obstruction
– Poor air exchange
– Increased breathing
difficulty
– Silent cough
– Cyanosis
– Inability to speak or
breath
• Children ≥ 1yo
– Abdominal thrust
• Infants ≤ 1yo
– Back slaps
– Chest thrust
Airway Obstruction
• Under 1yo risk of organ damage with abdominal
thrusts
• Give 5 back blows alternating with 5 chest thrusts
• Until relief or unresponsive
Airway Obstruction
• Your Abdominal blows are unsuccessful
• Other options???
• McGill Forceps
• R mainstem intubation of FB
• Surgical airway
Pediatric Surgical Airway
• Cricothyroidotomy
– Extremely difficult in kids <10yo (Almost
impossible)
– Too small an anatomical space for Seldinger kit
– Often Cricoid cartilage is the narrowest portion
so does not bypass the obstruction
Pediatric Surgical Airway
• Transtracheal jet ventilation
– 10 gauge needle or 14 gauge angiocath
– Standard wall source of O2
– Placed at the cricothyroid membrane or between the
tracheal rings inferior to the cricoid cartilage
– 3cc Syringe with plunger removed and a 90° angle
piece connected to an ambibag for kids <5yo
– Pressurized Jet Ventilator for kids >5yo
Case 3 Continued
• You successfully transtracheal ventilate the
patient below the obstruction and get good
chest rise and return of Oxygenation
• The patient remains in PEA…
Case 4
• 14yo healthy Male
• Motorcycle at 70km/hr hit the back of a
stationary truck
• Wearing Helmet
• Initially unconscious on scene and blood in
airway
• EMS arrival has agonal respirations and
then stops breathing….
Case 4
• On STARS arrival patient receiving CPR
and BVM ventilation
• PEA on the monitor
• Obvious facial trauma and bilateral UE
fractures
• Distended abdomen with periumbilical
bruising
Case 4
• Bilateral needle decompression performed
• Successful crash ETT placed
• Attempts x 2 by STARS medical crew for
IV line with no success
• Monitor continues to show organized
electrical activity but pulseless….
IV access in Peds
• Few things cause more distress to nonpediatric trained resuscitators
• Infants have small veins and often lots of
SC tissues
• Even more difficult in the sick child or
infant who is hypovolemic and peripherally
shut down
Vascular Access
• Peripheral IV
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Technically easy
Difficult in small children
Peripherally shut down
Rate limited flow
• Central line
• Technically challenging and time consuming
• Femoral, Internal jugular, Subclavian
• Larger bore
• Interosseous (IO)
The secret vein only anesthesia
seems to know about…
• Great Saphenous Vein
at the foot
• Consistently found
just anterior to the
medial malleolus
• May not be visible at
surface
• Large vein which is
easily cannulated
Interosseous
• Useful in all ages
• Previous recommendation was
after 90 seconds of attempts for
PIV
– Now recommendation is
immediately
• Allows for
• Fluids
• Drugs
• Bloodwork
• Technically easy
• Complications
– Compartment
– Infection
ETT drug administration
• Administration of drugs into the trachea results in
lower blood concentration than the same dose
given by IV/IO route
• Recent animal studies
– Show that the lower epinephrine concentrations
achieved when the drug is delivered by the
endotracheal route may produce transient β-adrenergic
effects.
– These effects can be detrimental, causing hypotension,
lower coronary artery perfusion pressure and flow, and
reduced potential for ROSC
Case 4 continued
• You get an IO running and after fluid
resuscitation with 1 liter of NS and 1 round
or Epi you get a pulse back
• The patient is transported to the ACH and
remains comatose
• The ICU resident asks you if you think we
should cool the patient???
Hypothermia ACLS
• Induced hypothermia may be considered if the
child remains comatose after resuscitation
– 32ºC to 34ºC for 12 to 24 hours
– Class IIb Evidence
– Extrapolated from Adult data
• The 2005 guidelines emphasize the importance of
avoiding hyperthermia
• Providers should monitor temperature and treat
fever aggressively
– Class IIb Evidence
Case 5
• 4yo M 15kg
• Known prior allergy to
bee stings
• Stung today at school
• Mother has Epi pen in
a drawer at home
• EMS arrives with him
at the ACH…
Exam
• Markedly swollen face
and eyes
• Lips and uvula
swollen
• Stridor noted
• Diffuse wheeze
• BP 70/51
• What would you like
to do?
Epi dosing in pediatrics
• Dose is always
0.01mg/kg
• In Resuscitation use
• In Anaphylaxis use
1:10,000 epinephrine
1:1000 epinephrine IM
IV/IO
– This is 1mg/ml =
0.01ml/kg IM
• 10kg = 0.1ml
• 20kg = 0.2ml
• 30kg = 0.3ml
– This is 0.1mg/ml =
0.1ml/kg IV/IO
• 10kg = 1ml
• 20kg = 2ml
• 30kg = 3ml
Case 6
• 8 month old male
• Found unresponsive and blue by parents at 0600 in
the morning
• EMS called and patch in indicating they are 5
mins out with Asystole on the monitor and doing
CPR
• Unable to get IV access
• You are preparing the trauma room and the team
for arrival of the patient….
Case 6
• Patient arrives in asystole with no signs of
life
• The nurse gets an IV line and you
administer Epinephrine and Atropine IV
followed by 1 minute of good CPR
• There is no response…
• What now?
When to quit?
• Prospective study of 300 kids in CPA
• No survivor received epinephrine
Sirbaugh et al. Annals of Emerg Med 1999. 33(174)
• 101 kids with CPA or resp arrest
• No survivors needed resuscitative efforts for more
than 20 minutes or > 2 doses of epinephrine
Schindler et al. New Eng J Med 1996. 335(1473-79)
Termination of efforts
• Multiple other studies
– Small sample sizes, heterogeneous populations,
retrospective designs, etc
– Some survival despite prolonged resuscitation
– Difficult to draw any firm conclusions
• Very little consensus in the literature to guide you
• PEA and Asystole may not carry the same
prognosis in peds as it does in adults
Current ACLS guidelines
• If a child fails to respond to two doses of
epinephrine with a ROSC the child is unlikely to
survive
• Resuscitative efforts may be ceased in pediatric
CPA victims after 30 minutes unless exceptional
circumstances exist
i.e.
• primary hypothermic insult
• toxic drug exposure
• recurrent or refractory VF/VT
• Cross sectional survey
– 160 PEM (70%)
– 127 GEM (62%)
• PEM were >2x more
likely to terminate
resuscitative efforts if
ROSC was not
achieved by 25 mins
Case 6
• You administer a 2nd round of epinephrine with no
effect and then ask if anyone has any other
suggestions
• After 20mins of efforts you call the resuscitation
and note the time of death
• The family members who have been present
during the resuscitation are screaming for you to
try and do something else
• They want to take the baby to another hospital
hoping that they will be able to try something….
Family Presence during resuscitaiton
• Traditionally family members were excluded
• The concept of family-centered care in the ED has
now become more widespread
• Overwhelmingly family members are in favour or
being present
• ED staff opinion has been mixed
• Many organizations now endorse family presence
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Extensive Review of the ED literature
Conclusions:
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Family presence should be an option for routine invasive
procedures in the ED
Family presence should be an option for critical resuscitation
and CPR in the ED
All members of the resuscitation team must be in agreement
Dedicated medical interpreter should accompany the patient
If family leaves during a critical phase of the resuscitation all
efforts should continue until family returns to allow final
moments with their dying child
Institutions should have guidelines
Trainees should be provided with skills and experience in
functioning under parental presence
Pediatric Death in ED
• No formal training in coping with pediatric deaths
• With ED death there is usually no established
relationship with the parents
• Viewed as particularly tragic with strong emotions
– Children aren't supposed to die
– It's not natural
– The child never had an opportunity to experience a full
life
Pediatric Death in ED
CRISIS
• Powerful and often
uncontrollable emotions
• Illogical or impaired
decision-making abilities
• Recruiting other team
members and family
members for support
GRIEF
• Begins with understanding
that the child's death is
real
• Allow (not force) family
members to see or hold
their dead child
• Prepare them for what
they may see
• Opportunity to take a
momento
Pediatric Death in ED
• Address family feelings of guilt
• Reassure families that they did not contribute (either by acts of
commission or omission) to the child's death
• Reassure families that every care procedure that could have
been implemented in the ED was implemented is important
• Health team debriefing
– Strengths and weaknesses of the resuscitation
– Each team member can have an opportunity to ask
questions or offer comments
Questions?